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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 33-35

Pulmonary function test in OSMF patients

1 Department of Oral Medicine and Radiology, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh, India
2 Nanded Rural Dental College and Research Center, Nanded, Maharashtra, India

Date of Submission11-Feb-2019
Date of Decision25-Jul-2019
Date of Acceptance12-Oct-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Rashmi Nivsarkar
C-95, Opposite MGM School, Gayatri Nagar, Raipur - 492 001, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_14_19

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Betel nut quid chewing is a common psychoactive substance or masticatory euphoriant used by 600 million people in the world and is a main etiological factor for Oral Submucous Fibrosis (OSMF). The areca nut metabolite arecoline causes aggravation of disease in asthmatics by increasing bronchoconstriction in a dose-dependent manner; however, the effect of betel (Areca catechu) nut chewing on the function of the normal human lungs is yet to be fully established. Aim: The aim of the study was to measure and to compare pulmonary function tests such as forced vital capacity (FVC), forced expiratory volume (FEV), FEV/FVC%, peak expiratory flow rate, and maximum voluntary capacity maximum voluntary capacity (MVV) between study groups (control and OSMF). Materials and Methods: The study population included 100 participants comprising 50 normal and 50 clinically diagnosed OSMF cases. Pulmonary function tests were assessed using spirometer. Data were statistically analyzed. Results: Pulmonary function tests were found to be decreased in OSMF patients when compared to controls. Conclusion: There were no statistically significant differences (P > 0.05) in the spirometry parameters between both the groups; however, a decrease in pulmonary function compared to normal can be a warning sign for obstructive and restrictive type of pulmonary disease.

Keywords: Areca nut, OSMF, pulmonary function test

How to cite this article:
Nivsarkar R, Deoghare A, Vishwakarma A, Salkar P. Pulmonary function test in OSMF patients. Indian J Dent Sci 2020;12:33-5

How to cite this URL:
Nivsarkar R, Deoghare A, Vishwakarma A, Salkar P. Pulmonary function test in OSMF patients. Indian J Dent Sci [serial online] 2020 [cited 2023 Nov 28];12:33-5. Available from: http://www.ijds.in/text.asp?2020/12/1/33/276882

  Introduction Top

Oral submucous fibrosis (OSF) is a premalignant disorder associated with the chewing of areca nut (betel nut). Areca nut is a seed that grows in much of the tropical Pacific, Asia, and parts of East Africa. The International Agency for Research on Cancer review concluded that areca nut is carcinogenic in humans and that it is linked to cancers of the oral cavity, pharynx, esophagus, liver, biliary tracts, and uterus. Commercially freeze-dried products such as pan masala, guthka, and mawa (areca and lime) have high concentrates of areca nut per chew and appear to cause OSF more rapidly than by self-prepared conventional betel quid that contains smaller amounts of areca nut.[1]

Areca nut affects almost all organs of the human body, including the brain, heart, lungs, gastrointestinal tract, and reproductive organs. It causes or aggravates preexisting conditions such as neuronal injury, myocardial infarction, cardiac arrhythmias, hepatotoxicity, asthma, central obesity, type II diabetes, hyperlipidemia, and metabolic syndrome.[2]

Arecoline – the major compound of areca nut – can induce various growth factors in OSF fibroblastsin vitro such as insulin-like growth factor-1 and keratinocyte growth factor-1, and basic protein cystatin C, but inhibits proinflammatory cytokines such as interleukin-6.[3] Areca flavonoids tannins and catechins cause upregulation of cytokines in lamina propria. It also leads to activation of transforming growth factor beta resulting in increased fibrosis by inhibiting collagenase enzyme activity and forming a more stable and nonsoluble collagen structure.[4] Arecoline stimulates another key molecule in the regulation of fibrosis – the hypoxia-inducible factor-1α (HIF-1α) – in a dose-dependent manner. Morphological features of OSMF, especially fibrosis, suggest a possibility of hypoxic environment in diseased tissues. The adaptation of cells to hypoxia seems to be facilitated through HIF-1α, and decreased oxygen tension leads to transcriptional induction of series of genes that participate in angiogenesis, iron metabolism, glucose metabolism, and cell proliferation/survival.[5] Arecoline is considered as the most important etiological factor, but the addition of peroxynitrite (a reaction product of cigarette smoking) and nicotine acted as a synergistic effect on the arecoline-induced cytotoxicity and glutathione depletion.[3]

Various case reports from different parts of the world have shown that the areca nut metabolite arecoline causes aggravation of disease in asthmatics by increasing bronchoconstriction in a dose-dependent manner.[6]

Serum iron, albumin, hemoglobin, trace elements, and other immunological factors such as cytokines and immunoglobulins are indicators of disease progress or intermediary pathways in the pathogenesis. Change in the serum concentration can be a landmark in the diagnosis of potentially malignant disorders.[5]

Pulmonary function testing is a routine procedure for the assessment and monitoring of respiratory diseases. It is a valuable tool for evaluating the respiratory system, representing an important adjuvant to the patient history, various lung imaging studies, and invasive testing such as bronchoscopy and open-lung biopsy.[7] Spirometric values vary according to age, height, sex, and body size.[8]

This study was conducted to evaluate the changes in pulmonary function values among normal controls and OSMF patients.

  Materials and Methods Top

The study population included 100 participants comprising 50 clinically diagnosed OSMF patients and 50 normal controls aged between 20 and 50 years.

The study included patients (n = 50) with a habit of chewing betel nut products and normal controls (n = 50) with no adverse habits. Patients suffering from any acute and chronic illness, respiratory disease, or allergy and those taking medication for OSMF were excluded from the study.

Each group was evaluated for different parameters such as height (cm) and weight (kg). Pulmonary function tests were as follows: forced vital capacity (FVC [L]), forced expiratory volume in 1 s (FEV1 [L]), FEV1/FVC%, peak expiratory flow rate (PEFR [L/min]), and maximum voluntary ventilation (MVV [L/min]).

Lung function tests were measured using computerized spirometer model no. “SPIRO-232” PK Morgan Medical Ltd. The participant was asked to stand in front of the spirometer and was asked to open his mouth. The mouthpiece of the spirometer was introduced into his mouth, and he was asked to close the lips around the mouthpiece tightly. Immediately, after the deep inspiration, he was asked to blow out the air as fast as possible into the mouthpiece.

  Results Top

There was no significant difference between the mean ages of the two study groups, and majority of the OSMF patients were of age range 35–42 years [Table 1]. Furthermore, it was found that there were a decrease in values of FVC, FEV1, PEFR, MVV, and their predicted values and an increase in FEV1/FVC ratio and its predicted value although this relation was not found to be significant [Table 2].
Table 1: Age-wise distribution of patients

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Table 2: Pulmonary function test values for normal and oral submucous fibrosis patients

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  Discussion Top

Spirometry is a commonly performed lung function test for pulmonary disease examination. Lung function interpretation depends on the comparison to reference values derived from a healthy population.[9]

Although the changes were not significant, the present study observed a fall in FEV1, FVC, PEFR, and MVV values. The decrease in FEV1, PEFR, and other flow rates indicates obstructive lung changes, and fall in FVC indicates restrictive lung changes.[10]

Datta and Yanga studied Melanesian males of age range 18–40 years and found that betel nut chewers had significantly reduced FVC and FEV1.[11] Although changes were not significant, the present study had similar results.

Sekkadde Kiyingi and Saweri looked at the effects of betel nut in healthy nonasthmatic individuals and found no changes in FEV1.[12]

Taylor et al. also tested arecoline inhalation in healthy individuals. Even though there was more bronchoconstriction found in asthmatic people (six of seven patients), one of six healthy individuals developed bronchoconstriction, concluding that arecoline causes constriction of bronchial smooth muscles, thereby causing difficulties in respiration, particularly in patients with respiratory tract disorder.[13]

In 2014 by Wang et al., a large sample of 600 asthma patients and 1200 controls were studied to investigate the connection between asthma and betel nut use. They found that a higher arecoline level was associated with worse lung function FEV1(rho = −0.359, P = 0.004) and FVC (rho = −0.309, P = 0.02) in the male asthma group and concluded that betel nut chewing results in esophageal inflammation and fibrosis that may result in aggravation of asthma (an obstructive lung disease).[14],[15]

In a study by Deng et al. (2001), areca nut chewing was labeled as chewing as a risk factor for bronchospasm and chest discomfort and reported adverse clinical manifestations following initial or heavy betel nut use as bronchoconstriction, aggravation of asthma, and even respiratory failure.[16],[17]

Pentoxifylline, a newer drug added in the treatment of OSMF, is a trisubstituted methylxanthine derivative, with numerous biologic activities. It is termed as a “rheologic modifier.” It improves microcirculation and results in inhibition of T- and B-cells along with degranulation of neutrophils.[18]

  Conclusion Top

Areca nut is an addictive substance consumed in many parts of the world by people of all the age groups. Areca nut chewers are predisposed to asthma as it causes bronchoconstriction and decreased FEV. Pulmonary function test is decreased in OSMF patients compared to normal controls. The decrease in pulmonary function can be a warning sign for obstructive and restrictive type of pulmonary disease. Possible effects of areca nut result in decreased FEV through increased arecoline levels and eotaxin-1 concentration, thereby reducing pulmonary function. Further research analyzing the association between OSMF patient and asthma should be prosecuted.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bhisey RA, Boucher BJ, Chen TH, Gajalakshmi V, Gupta PC, Hecht SS. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines. IARC Monogr Eval Carcinog Risks Hum 2004;85:1-334.  Back to cited text no. 1
Garg A, Chaturvedi P, Gupta PC. A review of the systemic adverse effects of areca nut or betel nut. Indian J Med Paediatr Oncol 2014;35:3-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
Wollina U, Verma SB, Ali FM, Patil K. Oral submucous fibrosis: An update. Clin Cosmet Investig Dermatol 2015;8:193-204.  Back to cited text no. 3
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S. Oral submucous fibrosis: Review on aetiology and pathogenesis. Oral Oncol 2006;42:561-8.  Back to cited text no. 4
Dalmia A, Hazarey V, Talkal R, Ganvir S, Purohit HJ, Guptaetal S. Role of hypoxia inducible factor-1α messenger RNA expression in malignant transformation of oral submucous fibrosis: A RT-PCR study. Transl Res Oral Oncol 2016;1:1-5.  Back to cited text no. 5
Gupta PC. Survey of sociodemographic characteristics of tobacco use among 99,598 individuals in Bombay, India using handheld computers. Tob Control 1996;5:114-20.  Back to cited text no. 6
Miller WF, Scacci R, Gast LR. Laboratory Evaluation of Pulmonary Function. Philadelphia: J.B. Lippincott; 1987.  Back to cited text no. 7
Golshan M, Nemat BM. Normal prediction equations of spirometric parameters in 799 healthy Iranian children and adolescents. Arch Iran Med 2000;3:109-13.  Back to cited text no. 8
Prasad BK, Sahay AP, Singh AK. Smoking women and their lung function tests. Kath Uni Med J 2003;2:142-4.  Back to cited text no. 9
Padmavathy KM. Comparative study of pulmonary function variables in relation to type of smoking. Indian J Physiol Pharmacol 2008;52:193-6.  Back to cited text no. 10
Datta S, Yanga JK. Comparison of the effects of chronic smoking and betel nut chewing on the respiratory and cardiovascular parameters in Melanesian male population. Med Sci Bull 2003;1:13-7.  Back to cited text no. 11
Sekkadde Kiyingi K, Saweri A. Betelnut chewing causes bronchoconstriction in some asthma patients. P N G Med J 1994;37:90-9.  Back to cited text no. 12
Taylor RF, Al-Jarad N, John LM, Barnes NC. Betel nut chewing and asthma. Lancet 1992;339:1134-6.  Back to cited text no. 13
Wang TN, Huang MS, Lin MC, Duh TH, Lee CH, Wang CC, et al. Betel chewing and arecoline affects eotaxin-1, asthma and lung function. PLoS One 2014;9:e91889.  Back to cited text no. 14
Wang FW, Tu MS, Chuang HY, Yu HC, Cheng LC, Hsu PI. Erosive esophagitis in asymptomatic subjects: Risk factors. Dig Dis Sci 2010;55:1320-4.  Back to cited text no. 15
Deng JF, Ger J, Tsai WJ, Kao WF, Yang CC. Acute toxicities of betel nut: Rare but probably overlooked events. J Toxicol Clin Toxicol 2001;39:355-60.  Back to cited text no. 16
Nelson BS, Heischober B. Betel nut: A common drug used by naturalized citizens from India, Far East Asia, and the South Pacific Islands. Ann Emerg Med 1999;34:238-43.  Back to cited text no. 17
Rawlins JM, Lam WL, Karoo RO, Naylor IL, Sharpe DT. Pentoxifylline inhibits mature burn scar fibroblasts in culture. Burns 2006;32:42-5.  Back to cited text no. 18


  [Table 1], [Table 2]


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